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A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply.

1. Administer oxygen. 2. Assess the blood pressure. 3. Start an intravenous (IV) line. 4. Prepare to administer morphine sulfate. 5. Place the client on bed rest in a supine position. 6. Prepare to administer warfarin sodium (Coumadin). 1,2,3,4 Rationale: If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bed rest, with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain and apprehension. An IV line also will be required, and vital signs must be monitored. Heparin therapy (not warfarin sodium) is administered.

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse?

1. "Why do you believe this?" 2. "Tell me more about the details of your belief." 3. "I hear what you are saying, but I don't share your belief." 4. "If you want a pass for tomorrow evening's movie, you'd better turn that light off this minute. 3 Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it. Option 1 places the client in a defensive position by asking "why." Option 2 encourages the client to expound on the belief when discussion should instead be limited. Option 4 threatens the client.

A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps?

1. Apply heat to the affected area. 2. Take acetaminophen (Tylenol) every 4 hours. 3. Self-administer calcium carbonate tablets three times daily. 4. Purchase a chewable antacid that contains calcium and take a tablet with each meal. A. Rationale: Leg cramps may be a result of compression of the nerves supplying the legs by the enlarging uterus, a reduced level of diffusible serum calcium, or an increase in serum phosphorus. In the pregnant woman who complains of leg cramps, the nurse would perform further assessments to ensure that the client is not experiencing thrombophlebitis. Once this has been ruled out, the nurse would instruct the woman to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or stand and walk. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level, but the nurse would not prescribe these or any other medications.

The nurse is instructing the post-cardiac surgery client about activity limitations for the first 6 weeks after hospital discharge. The nurse should include which item in the instructions?

1. Driving is permitted so long as the lap and shoulder seat belts are worn. 2. Lifting should be restricted to objects that do not weigh more than 25 pounds. 3. Use the arms for balance, not weight support, when getting out of bed or a chair. 4. Activities that involve straining may be resumed so long as they do not cause pain 3 Rationale: The client is taught to use the arms for balance, but not weight support, to avoid the effects of straining on the sternum. Typical discharge activity instructions for the first 6 weeks include instructing the client to lift nothing heavier than 5 pounds, to not drive, and to avoid any activities that cause straining. These limitations are to allow for sternal healing, which takes approximately 6 weeks.

After a tonsillectomy, a child is brought to the pediatric unit. The nurse should appropriately place the child in which position?

1. Prone 2. Supine 3. High Fowler's 4. Trendelenburg 1. The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage. Options 2, 3, and 4 will not achieve this goal.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?

1. Hypotension 2. Increased heart rate 3. Bounding peripheral pulses 4. Shortened QT interval on electrocardiography (ECG) 1 Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the electrocardiogram (ECG), the nurse would note a prolonged ST interval and a prolonged QT interval.

A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and the blood pressure has dropped. The nurse determines that the client is most likely experiencing which problem?

1. Sepsis 2.Air embolism 3. Fluid overload 4.Fluid imbalance Rationale: The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also may hear a loud churning sound over the pericardium on auscultation of the client's chest. The signs and symptoms of sepsis include fever, chills, and general malaise. Fluid overload causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a fluid imbalance depend on the type of imbalance the client is experiencing.

A nurse is assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. The nurse plans care with the understanding that the heart normally sends out how many liters of blood per minute to the body?

5 L/min

The nurse provides dietary instructions to a client with Ménière's disease. The nurse should tell the client that which food or fluid item is acceptable to consume?

got right but guessed 1.Tea 2. Coffee 3. Cold-cut meats 4. Sugar-free Jell-O Rationale: The underlying pathological changes of Ménière's disease include overproduction and defective absorption of endolymph. This increases the volume and pressure within the membranous labyrinth until distention results in rupture and mixing of the endolymph and perilymph fluids. Dietary therapy frequently is quite helpful in controlling the symptoms associated with Ménière's disease. The nurse encourages the client to follow a low-salt diet and to avoid caffeine, sugar, monosodium glutamate, and alcohol.

A client's electrocardiogram shows that the atrial and ventricular rhythms are irregular and there are no discernible P waves. The nurse recognizes that this pattern is associated with which condition?

right but iffy 1.Atrial flutter 2.Atrial fibrillation 3.Third-degree AV block 4. First-degree atrioventricular (AV) block 2 Rationale: With atrial fibrillation, the atrial and ventricular rhythms are irregular and there are usually no discernible P waves. In atrial flutter, the QRS complexes may be either regular or irregular, and the P waves occur as flutter waves. A client in third-degree AV block (also known as complete heart block) has regular atrial and ventricular rhythms, but there is no connection between the P waves and the QRS complexes. In other words, the PR interval is variable and the QRS complexes are normal or widened, with no relationship with the P waves. With first-degree AV block the PR interval is longer than normal, and there is a connection between the occurrence of P waves and that of QRS complexes.

The nurse is evaluating a client's cardiac rhythm strip to determine if there is proper function of the VVI mode pacemaker. Which denotes proper functioning?

1. Spikes precede all P waves and QRS complexes. 2. There are consistent spikes before each P wave. 3. Spikes occur before QRS complexes when intrinsic ventricular beats do not occur. 4. Spikes occur before all QRS complexes regardless of intrinsic ventricular activity. 3 Rationale: When a pacemaker is operating in the VVI mode, pacemaker spikes will be observed before the QRS complex if the client does not have their own intrinsic beat; therefore options 1, 2, and 4 are incorrect.

A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which vital sign is the most important for the nurse to check before administering the medication?

1. Temperature 2. Respirations 3. Blood pressure 4. Radial pulse rate 3 Rationale: Nitroglycerin acts directly on the smooth muscle of the blood vessels, causing relaxation and dilation. As a result, hypotension can occur. The nurse would check the client's blood pressure before administering the second nitroglycerin tablet. Although the respirations and apical pulse may be checked, these vital signs are not affected by this medication. The temperature also is not associated with administration of this medication.

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination?

1.Sims position 2.Supine with the head and feet flat 3.Supine with the head raised slightly and the knees slightly flexed 4.Semi-Fowler's position with the head raised 45 degrees and the knees flat 3Rationale: During the abdominal examination, the client lies supine (flat on the back) with the head raised slightly and the knees slightly flexed. This position relaxes the abdominal muscles. Sims position is a side-lying position and would not adequately expose the abdomen for examination. Placing the head and feet flat would result in the abdominal muscles' being taut. The abdomen cannot be accurately assessed if the head is raised 45 degrees.

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which is in the client's hospital room as a priority item?

1. Over-bed trapeze 2. Dry sterile dressings 3. Surgical tourniquet 4. Incentive spirometer 3. Rationale: Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore a surgical tourniquet is kept at the bedside in case of acute bleeding. An over-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items considering the surgical procedure that the client underwent.

A nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client?

1. Sclera 2. Oral mucosa 3. Soles of the foot 4. Palms of the hand 2. Rationale: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Jaundice would best be noted in the sclera of the eye. Cyanosis is best noted on the palms of the hands and soles of the feet.

A nurse reinforces medication instructions to a client who has received a kidney transplant about therapy with cyclosporine (Sandimmune). Which statement by the client would indicate a need for further instruction?

1. "I need to obtain a yearly influenza vaccine." 2. "I need to have dental checkups every 3 months." 3. "I need to self-monitor my blood pressure at home." 4. "I need to call the health care provider if my urine volume decreases or it becomes cloudy." 1 Rationale: Cyclosporine is an immunosuppressant medication. Because of the effects of the medication, the client should not receive any vaccinations without first consulting the health care provider. The client should report decreased urine output or cloudy urine, which could indicate kidney rejection or infection, respectively. The client needs meticulous oral care and dental cleaning every 3 months to help prevent gingival hyperplasia. The client must be able to self-monitor blood pressure to check for the side effect of hypertension.

A nurse provides home care instructions to a client undergoing hemodialysis with regard to care of a newly created arteriovenous (AV) fistula. Which client statement would indicate understanding of the instructions?

1. "I should check the fistula every day by feeling it for a vibration." 2. "I am glad that the laboratory will be able to draw my blood from the fistula." 3. "I should wear a shirt with tight arms to provide some compression on the fistula." 4. "I should check my blood pressure in the arm where I have my fistula every week." 1 Rationale: An AV fistula provides access to the client's bloodstream for the dialysis procedure. The client is instructed to monitor fistula patency daily by palpating for a thrill (vibration feeling). The client is instructed to avoid compressing the fistula with tight clothing or when sleeping, and that blood pressure measurements and blood draws should not be performed on the arm with the fistula. The client also is instructed to assess the fistula for signs and symptoms of infection, including pain, redness, swelling, and excessive warmth.

The home health care nurse is providing instructions to a client after a vulvectomy. Which instruction should the nurse provide to the client?

1. "You can engage in sexual activity in 2 weeks." 2. "It is all right to begin to drive a car as long as you do not drive long distances." 3. "Resume activities slowly, keeping in mind that walking is a beneficial activity." 4. "It is important to rest and sit in a chair with your legs elevated as much as possible." 3 Rationale: The client should resume activities slowly, and walking is a beneficial activity. Sexual activity is prohibited for approximately 4 to 6 weeks after surgery. Activities to be avoided include driving, heavy housework, wearing tight clothing, crossing the legs, and prolonged sitting and standing. The client should not be instructed to sit in a chair as much as possible because pressure on the surgical site could lead to complications related to the surgery.

A nurse provides dietary instructions to a client at risk for hypokalemia about which foods are high in potassium and should be included in the daily diet. The nurse should tell the client that which fruit is highest in potassium?

1. Kiwi 2. Apples 3. Peaches 4. Pineapple 1 Rationale: Foods that are high in potassium include bananas, cantaloupe, kiwi, and oranges. Fruits low in potassium include apples, cherries, grapefruit, peaches, pineapple, and cranberries.

A nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur?

1. She will feel some pain during the procedure. 2. She will be placed in a supine left side-lying position. 3. She will feel some pressure when the vaginal probe is moved. 4. She will need to drink 2 quarts of water to attain a full bladder. 3. Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound examination is well tolerated by most women because it alleviates the need for a full bladder to perform the test. The woman is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the woman may feel pressure as the probe is moved.

The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what should the nurse monitor as the priority?

1. Vital signs 2.Intake and output 3. Blood urea nitrogen results 4. Urine for glucose and ketone 1 Rationale: Pheochromocytoma is a catecholamine-producing tumor. Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a stroke or sudden blindness. Although all the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure.

A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute. Based on this finding, which is the appropriate nursing action?

1. Withhold the medication. 2. Administer the medication. 3. Double-check the apical heart rate and administer the medication. 4. Check the blood pressure and respirations and administer the medication 1. Rationale: Digoxin is a cardiac glycoside that is used to treat heart failure. A primary concern is digoxin toxicity and the nurse needs to monitor closely for signs of toxicity and monitor digoxin blood levels. The medication is effective within a narrow therapeutic digoxin range (1.0 to 2.0 ng/mL). Safety in administration is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats/minute in an infant, the nurse would withhold the dose and contact the health care provider. Therefore, options 2, 3, and 4 are incorrect actions; it would be harmful to administer the medication.

heart sound: ventricular hypertrophy

got right but iffy The sound that the nurse hears is the fourth heart sound (S4). Diastolic filling sounds or gallops (S3, the third heart sound, and S4, the fourth heart sound) are produced when there is decreased compliance of either or both ventricles. S3 is termed ventricular gallop, and S4 is referred to as atrial gallop. The S4 sound occurs in the later stage of diastole, during atrial contraction and active filling of the ventricles. It is a soft, low-pitched sound and is heard immediately before S1. An atrial gallop is found most commonly in disorders involving increased stiffness of the ventricle, such as ventricular hypertrophy, ischemia, and fibrosis. S4 is never heard in the absence of atrial contraction (atrial fibrillation). S4 is best heard with the bell of the stethoscope at the apex, with the client in the supine, left lateral position. The presence of S4 may also result from myocardial infarction, hypertension, hypertrophy, fibrosis, cardiomyopathy, cor pulmonale, aortic stenosis, or pulmonic stenosis. Therefore options 1, 2, and 4 are incorrect.

The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results?

1. Positive 2. Negative 3.Inconclusive 4. Definitive and requiring a repeat t 2. Induration measuring 15 mm or greater is considered a positive result in a child 4 years of age or older who has no associated risk factors. Options 1, 3, and 4 are incorrect interpretations.

The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which statement, if made by the client, would support the diagnosis of gastric ulcer?

got right but was iffy 1. "The pain doesn't usually come right after I eat." 2. "The pain gets so bad that it wakes me up at night." 3. "The pain that I get is located on the right side of my chest." 4. "My pain comes shortly after I eat, maybe a half-hour or so later. Home History Help Calculator Review ModeQuestion 42 of 75 Previous ▲ ▼ Go Next Stop Bookmark Rationale Strategy Reference(s) Submit The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which statement, if made by the client, would support the diagnosis of gastric ulcer?Rationale: Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by intake of food. The pain occurs 30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.

A client is taking ticlopidine hydrochloride (Ticlid). The nurse should tell the client to avoid which substance while taking this medication?

right but was iffy 1. Vitamin C 2. Vitamin D 3. Acetaminophen (Tylenol) 4. Acetylsalicylic acid (aspirin) 4 Rationale: Ticlopidine hydrochloride is a platelet aggregation inhibitor. It is used to decrease the risk of thrombotic stroke in clients with precursor symptoms. Because it is an antiplatelet agent, other medications that precipitate or aggravate bleeding should be avoided during its use. Therefore, aspirin or any aspirin-containing product should be avoided. The substances in options 1, 2, and 3 are safe to consume.